Form 776 "Inspection - Existing - Individual on-Site Wastewater Disposal System (Iowds)" - Mississippi

What Is Form 776?

This is a legal form that was released by the Mississippi Department of Health - a government authority operating within Mississippi. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 7, 2017;
  • The latest edition provided by the Mississippi Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 776 by clicking the link below or browse more documents and templates provided by the Mississippi Department of Health.

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Download Form 776 "Inspection - Existing - Individual on-Site Wastewater Disposal System (Iowds)" - Mississippi

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Page 1 of 4
 
Inspection
Existing – Individual On-site Wastewater Disposal System (IOWDS)
 
PROPERTY INFORMATION
(To be evaluated)
County:
Property Address:
City, State, Zip Code:
Number of Bedrooms:
Number of Occupants:
Subdivision Name & Lot
Acreage:
Number (if applicable)
APPLICANT INFORMATION
(How do we contact you?)
Name:
Mailing Address:
City, State, Zip Code:
Email Address:
Primary Telephone:
Secondary Telephone:
WATER SUPPLY
(Check one)
! Public (Water Meter)
! Private (Private Well)
 
REQUIRED WITH APPLICATION
Fee of $125.00 (a processing fee will be included for all electronic payments)
Legal Description – description of property in distances and bearings; usually attached or included in deed
to property
Plot Plan – drawing depicting location of buildings and any other improvements on the property
ATS Only: Inspection report from a Certified Installer/Factory Authorized Representative for your
particular brand
ATS Only: Continuing Maintenance Agreement (contract) from Certified Installer or become a
Qualified Homeowner
Send to: wastewater@msdh.ms.gov or Post Office Box 1700, Jackson, Mississippi 39215-1700 or apply online
at healthyms.com/wwapply
DIRECTIONS
(Indicate on lines below or provide on separate sheet of paper.)
Mississippi State Department of Health
Revised 8-7-17
Form 776
Page 1 of 4
 
Inspection
Existing – Individual On-site Wastewater Disposal System (IOWDS)
 
PROPERTY INFORMATION
(To be evaluated)
County:
Property Address:
City, State, Zip Code:
Number of Bedrooms:
Number of Occupants:
Subdivision Name & Lot
Acreage:
Number (if applicable)
APPLICANT INFORMATION
(How do we contact you?)
Name:
Mailing Address:
City, State, Zip Code:
Email Address:
Primary Telephone:
Secondary Telephone:
WATER SUPPLY
(Check one)
! Public (Water Meter)
! Private (Private Well)
 
REQUIRED WITH APPLICATION
Fee of $125.00 (a processing fee will be included for all electronic payments)
Legal Description – description of property in distances and bearings; usually attached or included in deed
to property
Plot Plan – drawing depicting location of buildings and any other improvements on the property
ATS Only: Inspection report from a Certified Installer/Factory Authorized Representative for your
particular brand
ATS Only: Continuing Maintenance Agreement (contract) from Certified Installer or become a
Qualified Homeowner
Send to: wastewater@msdh.ms.gov or Post Office Box 1700, Jackson, Mississippi 39215-1700 or apply online
at healthyms.com/wwapply
DIRECTIONS
(Indicate on lines below or provide on separate sheet of paper.)
Mississippi State Department of Health
Revised 8-7-17
Form 776
Page 2 of 4
 
Inspection
Existing – Individual On-site Wastewater Disposal System (IOWDS)
 
WASTEWATER SYSTEM HISTORY AND TYPE
 
 
Date of Installation:
Date of Last Repair:
!
Yes
Is this residence being lived in (currently
 
!
No
How long? ___________
occupied)?
 
(weeks/months/years)
!
Conventional (i.e., “Septic Tank and Underground Absorption”)
What type of on-site do you have?
!
Advanced Treatment System (ATS) (Spray, Drip or Overland)
 
!
Alternative (Elevated Sand Mound, Sand Filter or Plant Rock Filter)
 
SKETCH
 
S how ALL measurements of dwelling and system to property lines, well, driveway, swimming pool, pond, shed/shop, etc.)
ATTESTATION
By signing or typing my name in below, I attest that the information submitted is an accurate representation to the
best of my ability and knowledge. I understand that failure to include all relevant information on the application and
all requested documentation will deem my application incomplete. I understand my Individual On-site Wastewater
Disposal System can only be Accepted IF the residence is, and has been, occupied for the required time, no
failure/malfunction is observed at the time of inspection, and for Advanced Treatment Systems only, a Continuing
Maintenance Agreement is established.
I understand that any falsification of documentation or violation of regulations is punishable by Mississippi
Code of 1972, Annotated, Sections 41-67-5 (1), 41-67-7(4)(5), 41-67-28(5), 97-7-10, 97-9-59 and 97-9-61.
NOTE: If a malfunction of the Individual On-site Wastewater Disposal System is found, I will receive a
Permit/Recommendation and a NOTICE to make corrective measures within 30 days.
Or, IF the residence is unoccupied, or has not been occupied the required amount of time, I will only receive a
Permit/Recommendation for a new Individual On-site Wastewater Disposal System (IOWDS). I accept any risk with
using the existing system as is should the Department deem it unusable. Should a new system be installed on the
property, I must pay the final approval fee of $97.50.
Signature: _______________________________________
Date: _____________
Mississippi State Department of Health
Revised 8-7-17
Form 776
Page 3 of 4
 
Inspection
Existing – Individual On-site Wastewater Disposal System (IOWDS)
PURPOSE
To provide a notice to the Mississippi State Department of Health that an Applicant requests the inspection of an installed
(existing) Individual On-site Wastewater Disposal System
This documentation is not intended to be photocopied and released to the Applicant.
INSTRUCTIONS
The Applicant must provide all requested documents, written directions to the property, fee (or an email to receive an invoice at)
and read all pages. The Applicant agrees to authorize the environmentalist to enter the property to conduct an inspection of the
attested existing Individual On-site Wastewater Disposal System.
Property Information
1.
County – Enter the Mississippi county that the property is located in.
2.
Property Address – Enter the physical address (911 address) for the property location to be evaluated.
3.
City, State, Zip Code – Enter the City, State and Zip Code for the property address to be evaluated.
4.
Number of Bedrooms – Enter the actual number of bedrooms in the proposed residence.
5.
Number of Occupants – Enter the number of people who will be living in the residence.
6.
Acreage – Enter the size of the property in acres (if more than one residence/address is on the property, the
acreage for that individual residence).
7.
Subdivision and Lot Number – If applicable, enter the subdivision name and lot number
Applicant Information
8.
Name – Enter name of property owner(s).
9.
Mailing Address – Enter the complete mailing address of the Applicant.
10. City, State, Zip Code – Enter the City, State and Zip Code for the Applicant’s mailing address.
11. Email Address – Enter the Applicant’s email address.
12. Primary Telephone – Enter the telephone number the Applicant is most likely to use during business hours.
13. Secondary Telephone – Enter an alternate telephone number.
Water Supply
14. Check “public” if available source of water is a public water supply. Check “private” if source of water is an
individual (on-site) private well.
Required by Application
15. Additional paperwork that must be submitted with the Application as required by the Department to consider
the Application complete.
Directions
16. The Applicant must provide written, detailed directions to their property from the Department.
Wastewater System History and Type
17. Date of Installation – Enter date the system was installed.
18. Date of Repair – Enter date the system was repaired (if applicable).
19. Is residence being lived in (currently occupied)? – Check yes or no. If yes, enter length of occupancy.
20. What type of on-site system do you have? – Check the type of system at the site.
Sketch
21. Applicant must sketch a plat with the dwelling, wastewater disposal system and setbacks from property lines.
Attestation
22. Signature and date – Sign and date where indicated, confirming all portions of the Application are filled out
completely and accurately.
Mississippi State Department of Health
Revised 8-7-17
Form 776
Page 4 of 4
 
OFFICE MECHANICS AND FILING
The Applicant will complete the Inspection Application and include all requested documents and fee. The Division of On-Site
Wastewater will provide the Applicant with a copy of the inspection with the environmentalist’s signature and file an unsigned
copy in the Applicant’s file.
If any portion of the Inspection Application is considered incomplete, it will not be processed and the Applicant shall be notified
of what is missing. Once the Inspection Application is verified as complete, the Department will enter data into the wastewater
database. The Department will electronically file all documentation associated with the property.
RETENTION PERIOD
Signed copy has no retention time.
Copy unsigned in the file shall be retained for 3 years or until audited.
 
Mississippi State Department of Health
Revised 8-7-17
Form 776
Page of 4